Includes failures of the dedicated root cause analysis process, including initiation, investigator competence and training, evidence and stakeholder input, critical analysis, identification of lessons, action planning, completion and confirmation of resulting actions.
What is not included
Excludes generic incident investigation or organisational-learning failures where root cause analysis is not the specifically identified process.
Excludes failures in implementing safety actions where no root cause analysis or root cause analysis action plan is involved.
Excludes generic clinician training deficiencies unrelated to undertaking root cause analysis.
Excludes deficiencies in the underlying clinical or operational process investigated when the root cause analysis process itself is not unsafe.
Trends
Reports over time
Reports mentioning this concern, over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
NHS England3
Royal Stoke University Hospital3
Cwm Taf Morgannwg University Local Health Board2
Department of Health and Social Care2
Devon Partnership NHS Trust2
Enteral (GB) UK2
International Organization for Standardization2
Nursing Times2
University Hospitals Sussex NHS Foundation Trust2
Axminster Medical Practice1
Black Country Healthcare NHS Foundation Trust1
Care UK1
Central and North West London NHS Foundation Trust1
Derriford Hospital1
Dudley Integrated Health and Care NHS Trust1
NHS trust18
Healthcare site7
Executive non-departmental public body3
Company2
Local health board2
Ministerial department2
Multi-service care provider2
Prison or young offender institution2
Standards body2
Independent healthcare provider1
Medicines and medical devices regulator1
Reports and published responses 26 reports
See individual reports that have raised this concern, and the actions taken in response
West Sussex
Concerns raised1
Failure of Root Cause Analysis investigations to identify care and service delivery problems
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
University Hospitals Sussex NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
University Hospitals Sussex NHS Foundation Trust
Review processes for investigating perinatal deaths using RCOG and CQC best-practice models.
University Hospitals Sussex NHS Foundation Trust
Obtain Trust governance-team support to make Serious Incident root-cause analyses rigorous and objective.
University Hospitals Sussex NHS Foundation Trust
Implement the NHS England/Department of Health National Perinatal Mortality tool at the Trust when available from late 2017.
West Sussex
Concerns raised1
Failure to arrange a joint RCA of KMSS 111 and IC24 investigations
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Integrated Care 24
South East Coast Ambulance Service NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
South East Coast Ambulance Service NHS Foundation Trust
Confirm a date with IC24 to share the Trust’s Serious Incident report findings.
Integrated Care 24
Conduct a joint IC24–KMSS meeting to discuss cross-organisational learning and review the case.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
South East Coast Ambulance Service NHS Foundation Trust
The Trust has no further control after an out-of-hours referral is passed between independent organisations unless another call is received.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Integrated Care 24
A further joint RCA is considered unnecessary because joint learning has occurred and existing/new processes and actions are expected to yield no new learning.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Stoke-on-Trent and North Staffordshire
Concerns raised1
Failure to escalate matters for comprehensive serious incident or root cause review
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Exeter and Greater Devon
Concerns raised1
Failure to implement the action plan arising from the Root Cause Analysis
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Devon Partnership NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.10
Devon Partnership NHS Trust
Provide comprehensive assessments and formulate recovery, care and risk plans for people using CRHT services.
Devon Partnership NHS Trust
Reassess CRHT patients before discharge when increased risks have been identified.
Devon Partnership NHS Trust
Record all telephone calls received by CRHT teams in clinical records.
Devon Partnership NHS Trust
Document discharge awareness and routinely consult and inform people and carers about CRHT discharge decisions.
Devon Partnership NHS Trust
Register both CRHT teams for the Triangle of Care initiative.
Devon Partnership NHS Trust
Contact people on the day they are discharged from CRHT, using face-to-face or telephone contact according to risk.
Devon Partnership NHS Trust
Increase OPMH consultant input and provide CRHT teams with direct access to OPMH consultants or named backup.
Devon Partnership NHS Trust
Have CRHT staff attend weekly Rougemont discharge-planning meetings to improve Adult/OPMH communication.
Devon Partnership NHS Trust
Develop recovery plans face to face with people using CRHT services whenever safe and practicable.
Devon Partnership NHS Trust
Consider the wishes and opinions of people receiving services in clinical decision making.
Essex
Concerns raised1
Failure to conduct root cause analysis and develop lessons learned and an action plan
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner North London
Concerns raised1
Failure to share root cause analysis learning with relevant staff
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.